What to consider in a patient with recurring epistaxis, potentially due to dengue (Dengue virus infection) or tonsillopharyngitis (tonsil and pharynx inflammation)?

Recurrent Epistaxis: Key Considerations Beyond Local Causes

In a patient with recurrent epistaxis, you must systematically evaluate for underlying systemic causes including coagulopathy, anticoagulant use, hereditary hemorrhagic telangiectasia, and structural nasal pathology—while dengue should be considered only in endemic areas with appropriate clinical context, and tonsillopharyngitis is not a relevant cause of epistaxis. 1

Critical Initial Assessment

Document specific factors that increase bleeding frequency or severity: 1

• Anticoagulant or antiplatelet medications (warfarin, apixaban, aspirin, clopidogrel) 2, 3
• Bleeding disorders (thrombocytopenia, hemophilia, von Willebrand disease) 1
• Hypertension and atherosclerosis (particularly in elderly patients with posterior bleeds) 4
• Intranasal drug use (topical corticosteroids, cocaine, nasal decongestant overuse) 1
• Environmental factors (dry climate, low humidity, frequent nose picking) 5

Dengue Consideration: When and Why

Consider dengue fever only if: [@General Medicine Knowledge]

• Patient resides in or recently traveled to dengue-endemic areas (Southeast Asia, Latin America, Caribbean)
• Presents with fever, severe headache, retro-orbital pain, myalgias, or rash
• Has thrombocytopenia on complete blood count
• Epistaxis occurs during the critical phase (days 3-7 of illness) when capillary permeability increases

Dengue causes epistaxis through thrombocytopenia and vascular leak syndrome, not through direct nasal pathology. If dengue is suspected, obtain platelet count, hematocrit, and dengue serology. [@General Medicine Knowledge]

Tonsillopharyngitis: Not a Cause of Epistaxis

Tonsillopharyngitis does not cause epistaxis. [@General Medicine Knowledge] These are anatomically and pathophysiologically distinct conditions:

• Tonsillopharyngitis affects the oropharynx (tonsils and posterior pharyngeal wall)
• Epistaxis originates from the nasal cavity or nasopharynx
• If a patient has both symptoms simultaneously, they represent separate concurrent processes or the "epistaxis" is actually posterior pharyngeal bleeding from severe tonsillitis being mischaracterized

Systematic Evaluation for Recurrent Epistaxis

Physical Examination Priorities

Perform anterior rhinoscopy after removing blood clots to identify the bleeding source: [@2@, @4@]

• Kiesselbach's plexus (anterior septum) is the source in >90% of cases [@8@]
• Look for septal deviation, septal perforation, or visible telangiectasias [@2@, 1]
• Use a nasal speculum and headlamp for optimal visualization [@8@]

Proceed to nasal endoscopy if: [@2@, 1]

• Bleeding recurs despite prior packing or cautery
• Unilateral recurrent bleeding (raises concern for tumor or foreign body)
• Anterior rhinoscopy fails to identify a source
• Difficult-to-control bleeding suggests posterior source

Critical Red Flags Requiring Endoscopy

Nasal endoscopy is essential to exclude serious pathology in these scenarios: 1

• Adolescent males with unilateral profuse epistaxis (juvenile nasopharyngeal angiofibroma presents with epistaxis in 60-76% of cases) 1
• Unilateral nasal obstruction with epistaxis (nasal malignancy presents with epistaxis in 55% of cases) [1, @4@]
• Children with unilateral epistaxis, rhinorrhea, or foul smell (nasal foreign body causes epistaxis in 7% and is associated with bleeding in 30% of cases) [1, @4@]
• Disk battery foreign bodies require urgent removal (tissue necrosis and septal perforation can occur within 3 hours) 1

Hereditary Hemorrhagic Telangiectasia (HHT) Screening

Assess for HHT if the patient has: [@1@, @7@]

• Recurrent bilateral nosebleeds
• Family history of recurrent nosebleeds
• Visible nasal or oral mucosal telangiectasias on examination

HHT requires specialist referral for alternative management strategies beyond standard epistaxis treatment. [@7@]

Management Algorithm for Recurrent Epistaxis

First-Line Local Control (Regardless of Cause)

Apply firm sustained compression to the lower third of the nose for 5-15 minutes: [@5@, 3]

• Patient seated, head tilted slightly forward
• Breathe through mouth, spit out blood rather than swallow
• This alone controls bleeding in the majority of cases [@6@]

After compression, clean clots and apply topical vasoconstrictor: [2, @6@]

• Oxymetazoline or phenylephrine spray
• Stops bleeding in 65-75% of emergency department cases 5

If a specific bleeding site is identified, perform chemical cautery: [@4@, 5]

• Use 75% silver nitrate
• Anesthetize the site first
• Restrict cautery only to the active bleeding site
• Never cauterize both sides of the septum simultaneously (increases perforation risk) [@7@]

Preventive Measures for Recurrence

Aggressive nasal mucosal moisturization is the cornerstone of prevention: [@7@]

• Petroleum jelly to anterior nasal septum 1-3 times daily (especially before bedtime) [@5@, 3]
• Regular saline nasal sprays throughout the day [@5@, @6@]
• Bedside humidification during sleep (particularly in dry climates or winter) [@7@]

When Conservative Measures Fail

If bleeding persists despite compression and topical measures, proceed to nasal packing: [@5@, 3]

• Use resorbable packing for patients on anticoagulants or with bleeding disorders [@1@, @5@]
• Educate patient about packing type, removal timing, and warning signs requiring reassessment [@1@]

Refer to otolaryngology for persistent or recurrent bleeding despite packing: [1, @5@]

• Endoscopic sphenopalatine artery ligation (ELSA) has the best outcomes for persistent epistaxis: highest immediate success rate, shortest hospital stay, lowest recurrence rate, and highest patient satisfaction [@9@]
• Surgical arterial ligation or endovascular embolization have recurrence rates <10% versus 50% for nasal packing [@6@]

Critical Pitfall: Anticoagulation Management

In patients on anticoagulants (like apixaban), DO NOT routinely discontinue or reverse anticoagulation for recurrent epistaxis: [@5@, 3]

• Continue anticoagulation and aggressively pursue local control measures first [@7@]
• Withholding anticoagulation increases thrombotic risk, which carries higher morbidity and mortality than epistaxis itself 3
• Only consider temporary interruption if life-threatening bleeding is present (massive hemorrhage requiring transfusion, hemodynamic instability, or airway compromise) 3

Do not administer reversal agents, fresh frozen plasma, or platelet transfusions for non-life-threatening epistaxis (unnecessary risks without proven benefit) 3

Follow-Up Requirements

Document the outcome of intervention within 30 days: [1, @6@]

• Assess treatment effectiveness
• Identify need for alternative strategies
• Provide research opportunities for quality improvement

Educate patients about: [1, @5